LDSS-4826A DD (Rev. 3/17)

NEW YORK STATE OFFICE OF TEMPORARY AND DISABILITY ASSISTANCE

HOW TO COMPLETE THE SUPPLEMENTAL NUTRITION ASSISTANCE PROGRAM (SNAP) APPLICATION/RECERTIFICATION AND APPLICANT/RECIPIENT RIGHTS AND RESPONSIBILITIES FOR SNAP

This application can ONLY be used to apply for SNAP

If you are blind or seriously visually impaired and need an application or these instructions in an alternative format, you may request them from your social services district (SSD). The following alternative formats are available:

Applications and instructions are also available for download in large print, data format and audio format from www.otda.ny.gov. Please note that applications are available in audio format and Braille solely for informational purposes. In order to apply, you must submit an application in written, non-alternative format.

If you have any disabilities that prevent you from completing this application and/or from waiting to be interviewed, please notify your SSD. The SSD will make every effort to provide a reasonable accommodation to address your needs.

If you require another accommodation, or need other help completing this application, please contact your SSD. We are committed to assisting and supporting you in a professional and respectful manner.

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LDSS-4826A DD (Rev. 3/17)

NEW YORK STATE OFFICE OF TEMPORARY AND DISABILITY ASSISTANCE

HOW TO COMPLETE THE SUPPLEMENTAL NUTRITION ASSISTANCE PROGRAM (SNAP) APPLICATION/RECERTIFICATION AND APPLICANT/RECIPIENT RIGHTS AND RESPONSIBILITIES FOR SNAP

This application can ONLY be used to apply for SNAP

If you are only applying for SNAP you can use this shorter application. If you would like to apply for other benefits such as Temporary Assistance, Child Care Assistance, Home Energy Assistance or Medicaid please ask for a different application.

When You Are Applying For SNAP

Need SNAP Benefits Right Away? You May Be Eligible For Expedited Processing of your SNAP Application.

If your household has little or no income or liquid resources, or if your rent and utility expenses are more than your income and liquid resources, or you are a migrant or seasonal farmworker with little or no income or resources when you apply, you may be eligible to get SNAP within 5 calendar days of the date you apply. When a resident of an institution is jointly applying for SSI and SNAP prior to leaving the institution, the recorded filing date of the application is the date of release of the applicant from the institution.

Where You Can Apply For SNAP

If you live outside of New York City, you can apply on-line at myBenefits.ny.gov, or call or visit the social services district in the county where you live and ask for an application package, which can be mailed or dropped off to that appropriate office. You can get the address and phone number of the social services district in your county by calling toll free 1-800-342-3009.

If you live in New York City and you are not also applying for Temporary Assistance, you can apply on-line at myBenefits.ny.gov, or call or visit any SNAP Office and ask for an application package. You can get the address and phone number by calling 1-718-557-1399 or toll free 1-800-342-3009.

Having Problems Coming To Us For A SNAP Interview Appointment?

If it is difficult for you to come in for a SNAP interview appointment (reasons may include employment, health issues, transportation or child care problems), in some circumstances; we can interview you by telephone, or you may have someone else apply for you. Please contact your social services district if you have any questions, to see if you are eligible for a telephone interview, or if you need to reschedule an interview.

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INSTRUCTIONS ON HOW TO COMPLETE THE SNAP APPLICATION/RECERTIFICATION

Be sure to complete each section by PRINTING clearly in blue or black ink.

Do NOT print in the shaded areas.

If you are applying as someone’s representative, please print information about that person, not yourself.

ALTERNATIVE FORMATS: Check “YES” or “NO” to indicate whether you are blind or seriously visually impaired and would like to receive written notices in an alternative format. If "Yes," check the type of format you would like. Alternative formats are available in large print, data CD, audio CD, or Braille, if you assert that none of the other alternative formats are equally effective for you. If you require another accommodation, or need other help completing this application, please contact your SSD.

SECTION 1: APPLICANT INFORMATION

SECTION 2: Sign your name, date, and provide your address (if you have one) ONLY if you want to submit your application without completing the next page at this time to establish your application filing date. You must complete the application process, including the interview and sign on page 8 for us to determine your eligibility.

SECTION 3: HOUSEHOLD MEMBERS INFORMATION:

LIST THE NAMES OF EVERYONE WHO LIVES WITH YOU, EVEN IF THEY ARE NOT APPLYING WITH YOU.

SECTION 4: Answer all questions in section 4. Be sure to provide the names of individuals who are not U.S. citizens.

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SECTION 5: INCOME: List all your income and the income of everyone living with you. PRINT the name of the person receiving the income, the source of income and how often it is received. Income can include: Regular job (wages), income before strike, on-the-job-training, military reserves, national guard, work study, alimony, child support, educational assistance (grants, scholarships, etc.), friends or relatives (other than loans), temporary assistance, pensions or retirement, Supplemental Security Income (SSI), Social Security benefits, veterans benefits, unemployment benefits, worker’s compensation, babysitting, taxi driving, cleaning homes or other buildings, farming/ranching, income from a roomer, income from a boarder or arts and crafts.

NOTE: Foster Care Payments and SNAP – You may choose to include the foster care child or adult in the SNAP household. If you do, any associated foster care payments will be counted as income. All other income or resources of the foster care child also will be counted. If you have any questions about this, make sure to ask your worker.

Be sure to answer all other questions in section 5.

SECTION 6: RESOURCES: Resources do not affect the eligibility of most households applying for SNAP. However, some resource information is used to determine if you qualify for expedited processing of your application.

Answer all the questions in Section 6 for yourself and everyone who is applying for SNAP. List the dollar ($) amount or value and the name of the person who has the resource. Be sure to list any joint holdings with non-household members. Resources may include any of the following: cash on hand, cash held by others, checking or savings account, savings bonds, individual retirement account, pension plan, individual development account, stocks/bonds, mutual funds, trust fund, money market certificates, buildings, land, rental property, vacation or recreational property or house other than home.

SECTION 7: EDUCATION/TRAINING AND LANGUAGE: On the table, enter the name of each person in the household (including yourself) who is 16 years of age or older and put an “X” in the “Highest Level of Education” field to indicate whether each individual has less than a high school diploma and does not have a high school equivalency diploma (including those who are still attending high school or an equivalency program), obtained a high school diploma or high school equivalency diploma, obtained an Associate’s Degree (2-year college degree), obtained a Bachelor’s Degree (4-year college degree), obtained a Graduate Degree (Master’s Degree or higher); completed an Individualized Education Plan (IEP) and does not have a high school equivalency diploma, or the education level of the individual is Unknown. Also please answer “Primary” or “Secondary” if English is the individual’s primary or secondary language. The primary language is the language the individual speaks most often. The secondary language is the use of the English language by non-native speakers in an English-speaking environment. If English is not the primary language or secondary language, please enter “Neither” in the space provided.

The provision of this information is voluntary. It will not affect the eligibility of the persons applying or the level of benefits received. The information is requested to meet federal reporting requirements.

SECTION 8: LIVING ARRANGEMENTS AND EXPENSES:

PRINT the amount you pay for rent, mortgage, room and board or other housing. List the dollar ($) amount that you pay for your property taxes and homeowner’s insurance.

If you pay for your heat separately, check () what type of heat you have, and fill in the name of the heating company and your account number.

Also, indicate if:

Be sure to answer all other questions in section 8.

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SECTION 9: LEGAL STATEMENTS, RESPONSIBILITIES AND PENALTIES: Read this section carefully or have someone read it to you.

Note: NY State Law provides for fine or jail, or both, for a person found guilty of obtaining SNAP by hiding the facts or not telling the truth.

I understand that the State will use my Social Security Number to verify with my home energy vendors the receipt of HEAP. This authorization also includes permission for any of my home energy vendors (including my utility) to release certain statistical information, including but not limited to, my annual electricity usage, electricity costs, fuel consumption, fuel type, annual fuel cost and payment history to the Office of Temporary and Disability Assistance and the local Social Services District and the United States Department of Health and Human Services for the purposes of Low Income Home Energy Assistance Program (LIHEAP) performance measurement.

NON-DISCRIMINATION NOTICE – In accordance with Federal civil rights law and U.S. Department of Agriculture (USDA) civil rights regulations and policies, the USDA, its Agencies, offices, and employees, and institutions participating in or administering USDA programs are prohibited from discriminating based on race, color, national origin, sex, religious creed, disability, age, political beliefs, or reprisal or retaliation for prior civil rights activity in any program or activity conducted or funded by USDA.

Persons with disabilities who require alternative means of communication for program information (e.g. Braille, large print, audio tape, American Sign Language, etc.), should contact the Agency (State or local) where they applied for benefits. Individuals who are deaf, hard of hearing or have speech disabilities may contact USDA through the Federal Relay Service at (800) 877-8339. Additionally, program information may be made available in languages other than English.

To file a program complaint of discrimination, complete the USDA Program Discrimination Complaint Form, (AD-3027) found online at: http://www.ascr.usda.gov/complaint_filing_cust.html, and at any USDA office, or write a letter addressed to USDA and provide in the letter all of the information requested in the form. To request a copy of the complaint form, call (866) 632-9992. Submit your completed form or letter to USDA by:

  1. mail: U.S. Department of Agriculture
  2. fax: (202) 690-7442; or
  3. email: program.intake@usda.gov.

This institution is an equal opportunity provider.

SECTION 10: SNAP AUTHORIZED REPRESENTATIVE: If you want someone from outside your household to apply for SNAP benefits or get the SNAP benefits or to buy the food for you, PRINT their name, address and phone number, unless the authorized representative has been otherwise designated by the household in writing.

SECTION 11: SIGNATURES: Sign your name. If you are an Authorized Representative, both you and a responsible adult household member must sign and date the signature sections on page 8 of the Application/Recertification.

When an Authorized Representative is applying on behalf of a SNAP Household that does not reside in an institution, both the Authorized Representative and the Head of Household or another responsible adult member of the household must sign and date the signature sections on Page 8 of the Application/Recertification.

SECTION 12: ADDITIONAL INFORMATION: Use this section to let us know additional information that you think we might need to know.

SECTION 13: CONSENT TO WITHDRAW: If you decide you no longer wish to apply for SNAP, sign your name and enter date. You may reapply at any time.

Note: The last page of this application is an application to register to vote. If you would like help filling out the voter registration application form, ask your worker. Applying or declining to register to vote will not affect your eligibility or the amount of assistance that you will be given by this agency.


Information from your application and interview will be entered and stored in the Welfare Management System (WMS), a statewide computer system. This system is used to improve the management of Social Services Programs and to deter fraud.


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READ THE IMPORTANT INFORMATION BELOW

APPLICANT/RECIPIENT RIGHTS AND RESPONSIBILITIES FOR SNAP

Additional information regarding your rights and responsibilities is contained in the Client Information Books (LDSS-4148A; LDSS-4148B and LDSS-4148C). These books can be obtained at your social services district, and on-line.

YOU HAVE RIGHTS:

WHAT IS A FAIR HEARING

A Fair Hearing is a chance for you to tell an Administrative Law Judge from the New York State Office of Temporary and Disability Assistance why you think the social services district’s decision about your case was wrong. After the Fair Hearing, the State will issue a written decision which will state whether the social services district’s decision was right or wrong. The written decision may order the social services district to correct your case.

TIME LIMITS TO ASK FOR A FAIR HEARING

If you want to ask for a Fair Hearing for SNAP, call right away because there are time limits. If you wait too long, you may not be able to get a Fair Hearing. If you get a notice about your case and you want to ask for a Fair Hearing, the notice will tell you how much time you have to ask for the Fair Hearing. Be sure to read all of the notice carefully. If your notice tells you that your SNAP benefits have been denied, will be stopped or will be reduced, you may ask for a Fair Hearing within 90 days from the date of the notice. You may ask for a Fair Hearing if you think you are not getting enough SNAP benefits at any time within the certification period.

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HOW TO ASK FOR A FAIR HEARING

If you live anywhere in New York State, you may request a Fair Hearing by telephone, fax, online, or by writing to the address below.

Telephone: Statewide toll free request number is 800-342-3334. Please have the notice, if any, with you when you call.

Fax: your Fair Hearing Request to: 518-473-6735

Online: Complete online request form at http://www.otda.state.ny.us.us/oah/forms.asp

In writing: If you received a notice, fill in the supplied space and send a copy of the notice, or write to:

Walk-In: If you live in New York City you may also make your request in person by walking into the Office of Administrative Hearings, Office of Temporary & Disability Assistance, 14 Boerum Place, Brooklyn, New York

EMERGENCY - If your situation is very serious, the New York State Office of Temporary and Disability Assistance will set up a Fair Hearing for you as soon as possible. When you call or write for a Fair Hearing, be sure to explain that your situation is very serious.

NOTE: For New York City emergency fair hearings only – Call 800-205-0110. Do not use this telephone number for anything except emergencies. Requests that do not involve emergencies will not be taken at this number.

INTERPRETERS – You have the right to an interpreter at no cost to you, if English is not your primary language, or if you are hearing or speech impaired.

AID CONTINUING - If you get a notice telling you that your benefits will be stopped or reduced, and you ask for a Fair Hearing before the effective date on your notice, your SNAP benefits will, in most instances, stay the same ("aid continuing") until the Fair Hearing decision is made. If you do not get a notice about your case, and your benefits are stopped or reduced, at the same time that you ask for a Fair Hearing, you can ask that your SNAP benefits be restored ("aid continuing") until the Fair Hearing decision is made.

However, if you get "aid continuing" and you lose the Fair Hearing, you may have to pay back any benefits that you received as “aid continuing” while waiting for the Fair Hearing decision. If you do not want the SNAP benefits you have been getting to stay the same until the Fair Hearing decision is made, you must tell this to the New York State Office of Temporary and Disability Assistance when you call or write for a Fair Hearing.

HOW TO PREPARE FOR A FAIR HEARING

The New York State Office of Temporary and Disability Assistance will send you a notice, which tells you when and where the Fair Hearing will be held. To help you get ready for the Fair Hearing, you have the right to look at your case record and get free copies of the forms and papers which will be given to the Administrative Law Judge at the Fair Hearing. You can also get free copies of any other papers in your case record which you think you may need for the Fair Hearing. Usually, you can get these papers before the hearing or at the hearing at the latest. If you ask for any papers related to your hearing, and the social services district does not give them to you before or at the hearing, you should tell the Administrative Law Judge about it.

You should also bring to the Fair Hearing any witnesses who can help you and any information you have such as: Pay stubs, Bills, Receipts, Leases, Doctor’s statements, to help you explain why you think the social services district’s decision is wrong.

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You can bring a lawyer, a relative or a friend to the Fair Hearing to help you explain why you think a social services district’s decision about your case is wrong. If you think you need a lawyer to help you with your Fair Hearing, you may be able to get a lawyer at no cost to you by calling your local Legal Aid or Legal Services Office. For the names of other lawyers, call your local Bar Association.

Someone from the social services district will also be at the Fair Hearing to explain the social services district’s decision about your case. You or your representative will be able to question this person and any witnesses from the social services district.

If you cannot go to the Fair Hearing, you can send someone else in your place. If you are sending someone who is not a lawyer to the Fair Hearing, you must give this person a letter to give to the Administrative Law Judge. This letter should tell the Judge that you want this person to take your place at the Fair Hearing. If the Administrative Law Judge decides that your presence is required, and your testimony is necessary, the hearing may be re-scheduled for another day for you to appear. You will be notified of the new day by mail.

NOTE: If you ask, you will be able to get back the money you had to pay for public transportation, child care and other necessary expenses to go to the fair hearing. If no public transportation is available, you may be able to get back the money you had to pay for another type of transportation. If you are unable to use public transportation because of a medical problem, you may be able to get back the money you had to pay for another type of transportation. However, you may be asked to provide medical verification.

TO LOOK AT YOUR CASE AND COMPUTER RECORDS:

Once you apply for SNAP or other help, case records and computer records are kept about your case. Usually, you have the right to look at those records. However, you may not be able to look at all of the records. Your worker can explain the rules to you.

When you write for copies of your computer records, the Personal Privacy Protection Law requires that New York State agencies, send you your records; or tell you why they will not give you your records; or tell you they have your request and they will determine if you are allowed to get your records within five working days of when they get your request letter.

AS AN APPLICANT/RECIPIENT OF SNAP YOU HAVE SEVERAL RESPONSIBILITIES:

Employment Requirements for SNAP Applicants and Recipients

Unless you are exempt from work registration requirements, you must:

You are a work registrant and required to comply with work requirements unless you are determined by the social services official to be:

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If you fail to comply with a SNAP work assignment or quit a job, you may lose your SNAP benefits. The length of time you will lose your benefits depends on the number of times you have failed to comply with a work requirement.

Additional Work Requirements for SNAP Recipients who are Able-Bodied Adults without Dependents (ABAWDs)

If you are a work registrant/subject to SNAP work requirements, you also must meet additional SNAP eligibility requirements unless you are:

If you are a work registrant and not exempt due to one of the reasons listed above you are only eligible to receive SNAP benefits for three months in a 36 month period unless you:

If an ABAWD wants to receive SNAP benefits beyond the 3 month limit and is unable to secure paid employment of at least 80 hours a month, he/she should immediately contact the social services district to discuss what work or work programs may be available to permit the ABAWD to meet the work requirement.

If an ABAWD does not meet the work requirement and loses eligibility for SNAP, he/she may be able to receive SNAP again, if otherwise eligible, and should immediately contact the social services district to discuss what he/she needs to do to regain SNAP eligibility.

In addition, the ABAWD must provide documentation of participation in unpaid work activities on a monthly basis and report to the social services district within 10 days after the end of the month if his/her work hours go below 80 hours a month.

IF YOU ARE SUSPECTED OF FRAUD

If you find out that you are being investigated because your worker thinks you did not tell the truth about your case, you should talk to a lawyer. If you are charged with welfare fraud in criminal court, the court will, if you are eligible, assign a lawyer to represent you at no cost.

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RESPONSIBILITY TO RESCHEDULE A MISSED INTERVIEW:

As an Applicant/Recipient of SNAP, you are responsible to reschedule a missed interview before the 30th day after the date you applied to avoid losing SNAP.

RESPONSIBILITY TO PROVIDE PROOF

When you are applying for SNAP, you will be asked to provide proof of certain things. Your worker will advise you of what is needed. Document requirements may vary for different assistance programs. If the social services district already has proof of certain things that do not change such as social security number, you do not need to prove it again.

By having proof of identity and other important documents when you first apply for assistance, you may be able to get help sooner.

If you are dropping off documents at your social services office, ask for a receipt which should include the district name, your name, the date, time, list of each specific document being left, and the name of the worker giving you the receipt.

You must provide the proof that your worker tells you is needed to have your eligibility for SNAP determined. If you have trouble getting the requested proof, make it known to your worker.

NON-CITIZEN ELIGIBILITY INFORMATION

Many non-citizens are qualified aliens who are eligible for SNAP. Even if you are not, your children may be eligible. SNAP should not affect your immigration status with respect to any USCIS decision regarding your immigration matter.

You may be eligible for SNAP if you are a United States (U.S.) citizen, a non-citizen U.S. national (people born in American Samoa or Swains Island), or a qualified alien. A qualified alien for SNAP eligibility is:

  1. An American Indian born in Canada with at least 50 per centum of blood of the American Indian race under section 289 of the Immigration and Nationality Act (INA); or
  2. A member of a federally recognized Indian tribe under section 4(e) of the Indian Self-Determination and Education Assistance Act; or
  3. An alien admitted as a Hmong or Highland Laotian, including the spouse (or un-remarried surviving spouse) or unmarried dependent child; or
  4. A refugee admitted under section 207 of the INA; or
  5. An alien granted asylum under section 208 of the INA; or
  6. An alien whose deportation has been withheld under section 243(h) of the INA as in effect prior to April 1, 1997, or removal withheld under section 241(b)(3) of the INA; or
  7. An alien admitted as a Cuban or Haitian entrant under section 501(e) of the Refugee Education Assistance Act of 1980; or
  8. An alien who is a victim of trafficking under section 103(8) of the Trafficking Victims Protection Act of 2000; or
  9. A lawfully residing alien who is on active duty in the U.S. Armed Forces, an honorably discharged veteran whose discharge is not because of immigration status, his or her spouse, unmarried dependent children, or un-remarried surviving spouse; or
  10. An alien admitted as an Amerasian; or
  11. An alien lawfully admitted for permanent residence under the INA and who has 5 years in status; or
  12. An alien paroled under section 212(d)(5) of the INA for at least 1 year and who has 5 years in status; or
  13. A battered spouse or child, parent of a battered child or child of a battered parent with a petition pending or approved under 8 USC 1641(c) who entered before 8/22/96 or has 5 years in status; or
  14. Aliens also may be eligible for SNAP if: